Council Found to Have Provided Inadequate Care to Elderly Man


Watchdog forces it to apologise and pay daughter £500


Wandsworth Council Customer Services Centre

November 29, 2023

Wandsworth Council has been told to pay a woman £500 after placing her father in a nursing home which provided him with “inadequate care” before he died. A watchdog investigation found the woman was left with “uncertainty about whether the situation would have been different had the care provider acted as it should have done.”

The woman, named Ms C in the Local Government and Social Care Ombudsman report, said her father’s health “deteriorated rapidly” in the nursing home and alleged that the care provider failed to act when she raised concerns. Wandsworth Council placed Ms C’s father in the nursing home in August 2022 under a temporary arrangement. The nursing home is in Merton.

On a visit to the nursing home in September 2022, Ms C raised concerns with staff that her father was having a stroke after finding him slumped in a chair, unresponsive and unable to lift his arm. Staff told her he had improved from the previous day. He was taken to hospital later that week and found to have experienced a mini stroke.

Ms C’s father was discharged back to the nursing home on 4 October, by which point he had lost a significant amount of weight. He was later admitted to hospital on 28 November, where it was found he had no kidney function, was dehydrated and had sepsis. He passed away on 4 December.

The care provider later found Ms C’s father received care that fell “far below the standards to be expected” after an investigation, which also revealed failings in communication and a lack of effective oversight by management.

The care provider found concerns Ms C raised should have been dealt with more effectively, falls risk assessments had not been completed accurately and a carer who deliberately burst her father’s blister should not have done so.

Also among the findings was that records had shown consistent concerns about the decline in Ms C’s father’s health, but there were no documented actions taken or communication with Ms C to explore the reasons or offer an “appropriate caring response”, while his weight loss had not led to wider communication and an agreement on care required from that point.

Poor practice in the nursing home around documenting fluid intake was also identified and requirements for support with eating and drinking were found to have not been specific enough.

The ombudsman was satisfied Ms C’s father “received inadequate care” at the nursing home. The care provider said it had put in place training and reminders to staff following the investigation. Merton Council carried out a safeguarding enquiry as it is responsible for addressing outstanding issues with the care provider, and the ombudsman was satisfied it was taking action to address concerns raised.

The report said, “I understand Ms C’s concern about the failures the care provider has identified, especially as she had raised her own concerns about her father’s deterioration with the care provider and there is no evidence the care provider acted on those concerns. Nor is there any evidence the care provider acted on the concerns after Ms C met with the home manager.

“I understand why, in those circumstances, Ms C would believe inadequate care by the care provider caused or contributed to her father’s deterioration and subsequent death. However, only a coroner can comment on the cause of death or contributory factors in a death.”

It added, “I am satisfied though failures by the care provider, for which [Wandsworth Council] is responsible, likely caused Ms C significant distress and has left her with some uncertainty about whether the situation would have been different had the care provider acted as it should have done. That is a serious injustice.”

The ombudsman ordered the council to apologise and pay Ms C £500.

A Wandsworth Council spokesperson said, “This was a case where the care provided by this nursing home in Merton fell short of acceptable standards, for which we have offered our sincere apologies and agreed to pay compensation. The ombudsman’s report notes that Merton, as the local authority responsible for monitoring the care home, has taken the necessary action to address the safeguarding concerns arising from this case.”

A Merton Council spokesperson said: “We would like to offer our condolences to Ms C and her family. We note the findings and recommendations of the ombudsman. As stated in the report, we have undertaken our own safeguarding and quality investigations and worked with the nursing home to ensure that the issues are addressed and are not repeated.

“We are committed to ensuring that people supported by independent care providers in Merton are receiving the standard of care we would expect, irrespective of who places or funds the care.”


Charlotte Lillywhite - Local Democracy Reporter